Voice and speaking changes

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Dear Dr. Mahler: I have had PD for 10 years since I was first diagnosed. My progression has been slow so far according to my neurologist (lucky me). I have the usual symptoms, stiffness, balance, tremor, etc. all of which have been helped greatly by my med's and changes made to them by my Dr. I have over the last +/- 6-8 mo's have a problem with reocurring horseness making me sound like I have had a really bad cold. I was not sick. I also find that I am having problems speaking. I have begun starting and stopping my words as if I have to think about the word before it comes out. At times, that probobly is not a bad thing. Ha Ha. The hesitation while I am trying to carry on a conversation gets to be imbarrassing as I have never had a problem like the stuttering that I seem to have now. I'm beginning to have a problem with excess saliva at times. Are these all typical of the ongoing progression of PD or is it something else I should research with my Neurologist? Thanks in advance:

Shep

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Yes, these symptoms are characteristic of changes we expect in people who have PD. Speech problems are very common in people with Parkinson disease! It has been reported that as many as 89% of people with PD have trouble with their speech or voice. The most common difficulties include reduced vocal loudness, monotone, mumbled articulation and a hoarse or breathy sounding voice.

The underlying cause of some of speech and voice difficulties has multiple sources:

• Reduced vocal fold adduction

• Reduced mouth opening

• Decreased dynamic modulation of muscles of articulation

• Mismatch between the person’s perception of their loudness during communication and actual levels of loudness

There may also be difficulties initiating speech and slower thinking that are similar to difficulties in limb movements with delayed initiation and slowness of movement. Unfortunately, the medications that can be so helpful for improving limb movement don’t always have a positive effect for movement of speech muscles and increasing intelligibility. That is why people who have PD and communication difficulties need behavioral speech treatment.

Swallowing problems are very common also as the disease progresses. There are a number of reasons why swallowing can be "difficult" for a person with PD. The reason you need to get a referral for an evaluation with a speech- language pathologist (SLP) is so that they can identify the unique causes of the swallowing difficulty for you as an individual. The evaluation usually consists of an examination of the muscles for chewing and swallowing and then possibly a modified barium swallow study if the SLP suspects a problem in the pharyngeal stage (throat area) of the swallow that is more difficult to observe directly. When the evaluation is done the SLP should be able to describe your swallowing problems, the underlying physiology causing the problems, your risk for aspiration, and treatment strategies that appropriately address the cause of the problems.

Speak to your neurologist at your earliest opportunity and request an evaluation with a speech-language pathologist. Please write again if you have any additional questions.

I have had a speech analysis done for stuttering and halting rhythm, and provided exercises to do. Meds control when I am "on".

My volume has weakened some, but not noticeable.

Question: instead of softness of voice as I would expect, my voice is becoming deep and harsh...like I have been a life time cigar smoker. I have heard a similar tone from a woman with advanced MS. Could this be a result of the changes in the vocal cords you mentioned above...or a normal aging process... ? I have had two surgeries in the cervical area to remove parathyroids and thought perhaps scar tissue is forming. Should I expect this to continue and worsen? Can I delay worsening?

Thank you in advance for your time here on the forum.

New Normal

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Without seeing you in person, or more importantly, hearing you in person, I am reluctant to speculate about why your speech and voice may be worsening. Rapid rate and halting rhythm are often associated with PD and although speech may sound dysfluent, the disorder may not be a stuttering problem per se. There may be motor changes due to PD that are contributing making it more of a neurogenic stuttering or even palilalia. Voice changes are frequently caused by PD due to changes in motor control and there are voice changes that can be caused by surgery in the cervical area due to damage to the cranial nerve that controls the vocal cord muscles. My recommendation is that you see an otolaryngologist to directly examine your vocal folds. The American Speech, Language and Hearing Association recommends a laryngeal examination for all patients with voice disorders. Perceptual characteristics of PD that include reduced loudness, breathy or harsh voice quality, and reduced pitch range can overlap with other physiological changes in the vocal folds. The only way to definitively distinguish between these vocal fold pathologies is for an otolaryngologist to directly visualize the vocal folds and make a differential diagnosis. Another reason to complete an evaluation of the larynx is that many people with PD also have gastrointestinal dysfunction such as gastroesophageal reflux disease (GERD) that may be contributing to changes in your voice. The laryngeal evaluation may determine that medical and/or behavioral management of GERD is indicated prior to the initiation of treatment.

See the otolaryngologist and then take the results to a speech-language pathologist who specializes in treatment people with PD. Then you will have your answer about treatment interventions that can delay worsening of your speech, which is so important for a good quality of life.

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Hi---I am wondering if you have seen PD patients who have had normal speech before DBS surgery have fast talking after the surgery. Since my DBS, I seem to have the opposite problem from the above people. I talk like I am in a hurry and will stumble over my words. Instead of appearing like I am thinking about what I want to say, I feel like I have no control over my speech and will just talk without thinking. I really don't like it because I feel like I am offending my family and just rambling with no point in my talking. Is this a PD or DBS problem? thanks!

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This is a very good question. DBS for PD patients may have little effect on speech intelligibility and in some instances it may result in worsening of dysarthria and hypophonia (Dromey et al., 2000). There are a limited number of studies reported in the literature that have specifically addressed voice and speech behaviors after DBS and very few have used quantitative measures to analyze communication variables (D’Alatri et al., 2007). There is an article in the New England Journal of Medicine (Krack, et al. 2003, pgs 1925-1934), on a five-year follow-up of bilateral stimulation of the subthalamic nucleus in advanced Parkinson's disease. In the article it was documented that speech was one symptom resistant to improvement in patients post-surgery. Tripoliti et al., (2010) have identified stimulator placements and high stimulator settings that have a greater likelihood of a negative impact on speech.

It is probably a PD and DBS problem. It is very possible that speech treatment can help you. I suggest that you get a referral to a speech-language pathologist from your physician for an evaluation and treatment of this recent development since your DBS surgery.